Abstract
This paper reviews the current increase in the prevalence of childhood asthma, along with the current guidelines and approaches governed to reduce the frequency of hospitalizations as well as emergency visits. It reviews the disease state, the complications that come with it, and their prognosis. The paper seeks to discuss the role of the RN case manager, and their role in the overall management of chronic conditions. It covers the specific interventions and programs designed to incorporate the appropriate material geared towards self-sufficiency and management of asthma within the community. Additionally, it explores the desired outcomes and the quality of care provided to the specific population being discussed.
Introduction
The role of case management in the delivery of healthcare is a pivotal aspect that can be easily under looked. RN case managers work to plan, direct, and coordinate medical and health services that are designed and implemented for patients according to their individual needs and situations. Their efforts reach all levels of care, from adults, to infants, to those in the hospital, to people in rehab clinics. Pediatric asthma is one of the most serious chronic diseases that plagues infants and children, and although pediatric asthma cannot be cured, it can be managed. In fact, it is through programs enforced by RN case managers that allow for positive outcomes to be achieved through the effectiveness of proper interventions.
Population
The specific population targeted ranges in individuals from infants to adolescents under the age of 18. The scope and magnitude of the disease is extensive as childhood asthma is one of the most common chronic diseases affecting over 100 million globally, and more than 7% of the U.S. population. In recent years, the prevalence of asthma symptoms have globally increased in children and adolescents, largely in part to the host (genetics, atopy) and environmental factors such as microbial exposure, exposure to passive smoking, and air pollution, which seems to contribute to the observed increasing trends.
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As a result of such increasing numbers, the focus of nursing care has been directed toward self-management by implementing appropriate teaching through patient education, home treatment plans, and nurse follow ups, which in a study done by Dinelli and Higgins (2002), resulted in, “Favorable changes after intervention that included a decrease in clinic visits, a decreased use in oral anti-inflammatory drugs, and an increase in savings in regards to cost.”
Also, according to a meta-analysis and systemic review by Guevera (2003), showed that “An analysis of educational programs aimed at self-management of asthma in children and adolescents showed an improvement in measures such as lung function, self-efficacy, absenteeism, emergency department visits, restricted activity, and nights with asthma symptoms.” Overall, the goal is to not only target, but to reach the entire pediatric asthmatic population by improving their overall health, providing preventative services to children in need, and reducing the number of asthma related emergencies that lead to hospitalization.
Disease State
Pediatric Asthma is a chronic condition that consistently ravages the lungs of children. It is always there, even when the symptoms are not present. According to the NHLBI, “ Asthma is a chronic lung disease that inflames and narrows the airways, causing recurring periods of wheezing, chest tightness, shortness of breath, and coughing which often occurs at night or early morning.” with narrowing and swelling of the airways, less air is allowed into the lungs therefore affecting your overall wellbeing. Symptoms can be triggered or exacerbated by many external, as well as internal factors such as activity, the environment, food and drinks, certain medications, and colds at any given time hence the need for education and management.
Maintaining good asthma control is a long term process as there is no cure for the disease, because of that, it’s real easy to see why the proper support and care provided by case management is necessary to raise awareness and prevent worsening disease states. Because the goal is to keep children out of the hospital, case managers play a big role in participating with children and their families in schools, in the community, and in their homes to catch the early warning signs of asthma, ensure the proper usage of medications, coordinate care, and provide education in an effort to reduce hospitalizations and make significant health improvements to the pediatric population.
Delivery. As stated previously, the goal of case management in pediatric asthma is to prevent hospital admission and emergency visits, therefore care is going to be delivered in areas other than the hospital. Successful programs delivering preventative measures typically occur in the outpatient setting, in the community, over the phone, and in the patient home. These programs are designed to simultaneously control the disease while improving the quality of life and reducing costs. For example, programs like the “Yes We Can” initiative offered by the CDC target specific components of case management which are geared toward providing clinicians with the proper tools to set up population based care in their own communities.
In Alameda county specifically, the ACPHD offers a program known as the Asthma start program. This resource was enacted under the strategic plan for asthma in California during the 2014-2019 years. This program works with families of children with asthma by providing in-home case management services. The Asthma Start team provides education and support, and develops an action plan to assist families in controlling their children’s asthma. After contacting them over the phone, their mission and goals became clear, they offer in home education about asthma, asthma triggers, preventing asthma attacks and how to use medications. They offer in home visits to inspect and identify possible triggers, and they work with neighboring schools to ensure they have the needed supplies available for every child who needs them.
Once admitted into the program, the typical length fluctuates on the severity of the child’s asthma but varies anywhere from 3-6 months up to a year which includes 3-5 home visits within that time period. Once management has occurred, they have completed the program and can return anytime should their condition worsen or change. Eligibility is simple, and their mission is clear. According to the ACPHD, their goals are to “prevent emergency room visits and hospitalizations related to asthma, enhance awareness and understanding of asthma, improve the ability of families to control their child’s asthma, and prevent missed days from work and school.”
Outcome. In Alameda county, asthma is the leading cause of hospital stays for young children. As a result, the mission goal of the asthma start program is to prevent emergency room visits and hospitalizations related to asthma, which has seen major success. According to the ACPHD, “before enrolling in the asthma start program, 45% of families had kids hospitalized in the past year, a year later after enrollment, that number drops to 4%.”
Quality of Care
Diagnosing asthma in young children can be difficult, with varying types and causes for wheezing, there can be a number of childhood conditions with similar symptoms to asthma. As a result, there are standards of care and guidelines which provide helpful approaches to clinicians that allow them to properly assess and treat using the appropriate interventions. According to NHLBI, there are currently “four guidelines for the essential components of asthma care, which include assessment and monitoring, patient education, the control of factors contributing to asthma severity, and pharmacological treatment.” The most recent standards and guidelines were updated to help enlist even greater numbers of primary care clinicians, asthma specialists, health care systems, and communities to join together in making asthma care available to all people who have asthma.
Some of the focuses as stated by NHLBI (2007) include an “emphasis on multifaceted approaches to patient education and the control of the environment, establishing diagnosis, and assessing severity early on to promote early treatment.” The goals that are led by these standards are to catch symptoms early before hospitalization is needed, and to manage treatment properly early on to prevent exacerbations or severe episodes of asthma attacks. Now, because a majority of treatment and management is now geared towards care delivery outside of the hospital and into the community and the home, in order to uphold those standards of care and adhere to the guidelines, nurses must be well versed in identifying possible asthmatic systems, triggers, unsafe environmental conditions, and how to administer and properly use medications.
Nurses can actually study for, and take an exam to become certified asthma educators. While a majority of the case management role is geared towards care outside of the hospital system, that does not go on to say that the level of knowledge and care is not useful for the bedside nurse. Being well educated on the signs and symptoms of asthma is essential inside of the hospital for monitoring the ongoing conditions of patients. Patient education is also an important aspect of hospital care, especially in the asthmatic child, for example, learning new medications along with managing their conditions and the environment are all essential key factors to bedside care. The overall goal is to prevent hospitalization, however, should it occur, the bedside nurse should be just as prepared as the case manager in the community to prevent readmission.
Conclusion
In closing, RN case managers have a bulk responsibility in providing individualized care that meets the requirements of each patient. By adhering to the standards of care and using the guidelines as active tools, case management ensures an equal level of care for everyone. Whether that care is in the hospital, the community, or in the home, they are the muscle behind, and on the scenes that provide direct assistance through various health enhancing programs. Alameda county along with the rest of the U.S. have made it a mission to battle the increasing prevalence of asthma in children through programs that provide individualized care, education, and support to families dealing with childhood asthma. The Asthma Start Program, which serves Alameda County works with the families of children with asthma by providing in-home case management services, it also provides education and support, and develops an action plan to assist families in controlling their children’s asthma. While asthma cannot be cured, by using the tools provided to you through the community, it can be managed properly and children can live a full life without symptoms.
References
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